Growing Capable Parent Consent Form

Growing Capable Playgroup Intake Form

Fill in the below sections to book into our developmental play group.
Childs First Name:
Childs Last Name:
DOB:

DayMonthYear
Parent/Guardian Name:
Phone Number
Format: 0000000000.
Email:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preschool/ School

Rows Name Days attending

School/ Preschool
What are your child's strengths?
What are your concerns for your child's development?
Does your child have any medical or disability diagnosis?
Does your child see any other medical or allied health professionals?

Name / OrganisationPhone / Email
Alternate contact

Name / RelationPhone / Email
Does your child take any medications?
Please click on the following links to review our CKSC Privacy & Confidentiality Policy:

Privacy Policy
CKSC Policy acknowledgment
I consent for Capable Kids South Coast (CKSC) to contact and exchange information with the services listed in regards to my child
Social media consent:
At times, screeners may occur in a shared space with another family. If you are not comfortable with this and would like a private room, please advise below.

Rows	Name	Days attending
School/ Preschool

Form completed by:

Rows	Name	Relation	Date
1.

NOTE: Please advise us immediately if there are any court orders in place or if there is anyone specifically we are not to discuss your child's sessions with.
Should be Empty:

Growing Capable Playgroup Intake Form